Five year outcomes for users of mental health rehabilitation services: a
retrospective cohort study
Panagiotis Zis, Academic Core Trainee in Psychiatry1,2
Helen Killaspy, Reader in Rehabilitation Psychiatry1,2
Word count 1200
1Department
of Mental Health Sciences, University College London,
Charles Bell House, 67-73 Riding House Street, London W1W 7EJ
2Camden
and Islington NHS Foundation Trust, St Pancras Hospital, 4 St
Pancras Way, London, NW1 OPE
1
Summary
Five year outcomes for mental health rehabilitation service users surveyed in
2005 were investigated retrospectively through case note review. Two thirds
had a positive outcome, defined for those who were inpatients in 2005 as
achieving and sustaining community discharge, and for those who were
community patients in 2005 as sustaining the community placement/moving to
a less supported facility. Overall, 40% progressed to more independent
settings and 9% achieved independent living. Reported medication nonadherence increased the odds of not progressing (OR 8.60, 95% CI 3.4121.70). Interventions to improve medication adherence are required.
2
Introduction
Mental health rehabilitation aims to promote autonomy for people with longer
term and complex problems1. UK rehabilitation services developed during the
deinstitutionalisation era and have evolved to incorporate a whole system
approach to facilitate successful community living for this group 2. While long
term studies of those discharged from asylums found positive outcomes for
most3, there have been no studies investigating outcomes for users of
contemporary mental health rehabilitation services. We aimed to investigate
five year outcomes for users of one service and identify associated factors.
Method
Sample
In 2005, all 141 users of an inner city mental health rehabilitation service were
surveyed4 using standardised assessments of social functioning5, substance
use6, challenging behaviours7 and needs8. Approval was gained from the
local Research Ethics Committee to review this cohort’s case notes for the
purposes of this study.
Data
Outcome data were collected for the five years from the date each individual
was surveyed (April to August 2005). Any deaths, discharges or loss of
contact with services were noted and any recorded episodes of medication
non-adherence. Positive outcome was defined as follows: for those who were
inpatients at the time of the original survey, being discharged to the
community and maintaining the placement or moving to a less supported
placement, with no subsequent readmissions or placement breakdowns; for
those who were community patients at the time of the original survey,
maintaining the same community placement, or moving to a placement with
the same level of support, or moving to a less supported placement, with no
placement breakdowns or hospital admissions. Additional data were collected
on factors potentially associated with outcome (education history, family
history of mental illness, history of childhood separation or abuse, medical
history, medication prescribed in 2005).
3
Analysis
Data were analysed using the statistical software package SPSS (v 14.0).
Descriptive statistics were examined (table 1) and univariate comparisons
made between patients who had positive and negative outcomes (table 2).
Where statistically significant differences were found and full data were
available, variables were included in a logistic regression model to identify
factors associated with outcome. Since community patients only had to
maintain their placement to be classified as having a positive outcome
whereas inpatients had to progress to discharge, the regression was repeated
assigning a positive outcome to community patients only if they moved to and
sustained a less supported placement during the five years.
Results
Case notes were available for 140 patients, of whom 17 (12%) had died (all
from natural causes) and were excluded from the analysis. Of the remaining
123, two had been discharged from services and were categorized as having
a positive outcome. One third (42/123, 36%) were inpatients in 2005. Five
years later, 82 (67%) had a positive outcome. Of these, 27 (33%) had been
inpatients in 2005, 23 (28%) were community patients who successfully
moved to a less supported setting, and 32 (26%) maintained the same
community placement or one with similar support. The first regression
analysis therefore compared 82 patients with a positive outcome and 41 with
a negative outcome. The second regression compared 50 patients with a
positive outcome and 73 with a negative outcome. Over the five years, 11
patients (9%) achieved independent living.
Demographic data, diagnosis and psychiatric history were reported
previously4. The mean age was 44 years, 83 (68%) were male and 96 (78%)
had never married or cohabited. The majority (114, 93%) had a diagnosis of
schizophrenia or schizoaffective disorder. The mean length of illness was 22
years (SD 12).
4
Those with a positive outcome were older than those with a negative outcome
(mean age 46.78 vs 38.90 years, mean diff. 7.88, 95% CI 3.13 to 12.63,
p=0.001), had a longer history of mental illness (23.95 vs 17.27 years, mean
diff. 6.68, 95% CI 2.17 to 11.19, p=0.004), had lower scores on the social
function communication sub-scale5 score in 2005 (18.73 vs 20.37, mean diff. 1.63, 95% CI -2.78 to -0.48, p= 0.006) and lower scores on the challenging
behavior sub-scale C7 in 2005 (0.17 vs 0.34, mean diff. -0.17, 95% CI -0.33 to
-0.01, p=0.033) which assesses non-adherence with medication, absconding
and substance misuse. Those with a negative outcome were more likely to
have a history of physical abuse in childhood than those with a positive
outcome (8/41 [19%] vs. 6/82 [7%], 2 = 4.03, df 1, p=0.045), to have been
involuntarily detained in 2005 (9/41 [22%] vs. 6/82 [7%], 2 = 5.47, df 1,
p=0.019), and to have had at least one period of non-adherence with
medication recorded in the case file between 2005 and 2010 (38/41 [93%] vs.
30/52 [58%], 2 = 34.79, df 1, p<0.001).
These factors were entered into the first logistic regression model as
independent variables with the binary outcome as the dependent variable.
Although the full model significantly predicted outcome (2 = 61.97, df = 7,
p<0.001), the variance (39 to 55%) was explained by two variables; age and
medication non-adherence. Each increased year of age was associated with
a decrease in the odds of a negative outcome by a factor of 0.93 (95% CI
0.89 - 0.98). Having any recorded episodes of medication non-adherence
between 2005 and 2010 was associated with a 32.42 fold increase in the
odds of a negative outcome (95% CI 7.56 -138.92).
However, when the stricter definition of outcome was applied in the second
regression model, the only factor that remained statistically significant was
having any recorded episode of medication non-adherence. This was
associated with an increase in the odds of a negative outcome by a factor of
8.60 (95% CI 3.41 to 21.70). See Table 3.
5
Discussion
The majority of mental health rehabilitation service users in this study had a
positive outcome, with around two thirds achieving and/or sustaining
community placement over five years. However, despite good local provision
of a range of supported accommodation4, only 40% actually progressed to a
less supported community setting and less than 10% achieved fully
independent living, highlighting the importance of holding a “long term view”
for this group2. We found that non-adherence with medication influenced
outcome.
Our results should be interpreted with some caution given the limitations of
our design. Since retrospective studies are susceptible to recall bias, we
attempted to minimise this through the use of case note data and data from
standardised measures used in the original survey. Nevertheless, staff may
have been more likely to record medication non-adherence if a patient was
relapsing, thus we may have over estimated the importance of this factor.
However, this finding is corroborated by other outcome studies of people with
psychosis9,10. We avoided bias from missing data by only including variables
in our regression analysis where data were available on the whole cohort.
This may have meant that other important variables were excluded. Finally,
our cohort comprised users of one service, and results may not be
generalisable to other settings.
Many supported accommodation facilities are not funded to administer
medication and require service users to self-medicate11. Our findings suggest
that better outcomes could be achieved through a greater focus on this area.
Increased support and interventions that improve insight may be helpful12.
Evaluations of more controversial approaches such as incentivisation 13 and
the use of Community Treatment Orders14 will be of interest in this debate.
6
Author Contribution
Dr Killaspy conceived and designed the study. Dr Zis collected and analysed
the data. Both authors were involved in the drafting and revision of the article
and approved the final version.
Acknowledgements
We would like to thank Sarah White for her helpful advice regarding data
analysis and Professor Michael King for commenting on this manuscript.
Declaration of Interest
None
7
Table 1. Demographics, diagnosis and history
Total
Progressed Stable
Relapsed
Mean (SD) age in years
N=123
(100)
44 (13)
N=50
(41)
44 (14)
N=32
(26)
51 (11)
N=41
(33)
39 (12)
Male (%)
83 (68)
31 (62)
21 (66)
31 (76)
70 (57)
12 (10)
9 (7)
7 (6)
6 (5)
19 (15)
31 (62)
3 (6)
4 (8)
3 (6)
2 (4)
7 (14)
18 (56)
2 (6)
1 (3)
1 (3)
3 (10)
7 (22)
21 (51)
7 (17)
4 (10)
3 (8)
1 (2)
5 (12)
96 (78)
4 (3)
21 (17)
2 (2)
22 (12)
38 (76)
1 (2)
10 (20)
1 (2)
21 (13)
24 (75)
2 (6)
5 (16)
1 (3)
28 (11)
34 (83)
1 (2)
6 (15)
N=105
7 (4)
N=44
6 (4)
N=24
7 (4)
N=37
7(4)
114 (93)
3 (2)
3 (2)
2 (2)
1 (1)
0 (0)
47 (94)
1 (2)
1 (2)
1 (2)
0 (0)
0 (0)
31 (97)
0 (0)
1 (3)
0 (0)
0 (0)
0 (0)
36 (89)
2 (5)
1 (2)
1 (2)
1 (2)
0 (0)
101 (82)
6 (5)
7 (6)
1 (1)
3 (2)
1 (1)
4 (3)
3 (4)
40 (80)
1 (2)
4 (8)
0 (0)
2 (4)
0 (0)
3 (6)
3 (5)
28 (88)
1 (3)
1 (3)
0 (0)
0 (0)
1 (3)
1 (3)
5 (5)
33 (81)
4 (10)
2 (5)
1 (2)
1 (2)
0 (0)
0 (0)
2 (3)
Ethnic group (%)
White
Black Caribbean
Black African
Black other
Asian
Other
Marital status (%)
Never married
Married/living as married
Divorced/separated
Unknown
Mean (SD) years contact
with psychiatric services
Mean (SD) previous
admissions
Diagnosis (%)
Schizophrenia /sczaffective
Bipolar affective disorder
Depression
Personality disorder
Asperger’s syndrome
Other
Secondary diagnosis (%)
No other diagnosis
Substance misuse
Learning disability
Organic brain injury
Personality disorder
Schizophrenia
Anxiety/depression/OCD
Mean (SD) years in
placement (2005)
17 (10)
8
Table 2. Independent Factors Predicting Outcome
Positive
N=82
(67%)
Negative
N=41
(33%)
P values
46.78 (12.99)
38.90 (11.59)
p=0.001
Age at 1st contact with the 22.76 (9.42)
services (n=112)
22.02 (6.77)
p=0.661
Age at 1st admission to
rehabilitation services
(n=103)
Difference in years
(n=100)
38.94 (12.84)
33.56 (10.44)
p=0.03
17.09 (12.25)
11.17 (11.07)
p=0.026
Difference in years
between 1st contact and
1st rehab admission
(n=100)
17.09 (12.25)
11.17 (7.77)
p=0.026
Length of mental health
history in years (until
2005)
Number of Admissions
before rehabiliation
(n=86)
Total Number of
Admissions
23.95 (12.58)
17.27 (10.44)
p=0.004
5.00 (3.31)
5.53 (3.75)
p=0.493
6.24 (3.51)
7.64 (4.42)
p=0.081
Family Hx of mental
ilness
Yes 25
No 57
Yes 18
No 23
p=0.141
Medical Hx
Yes 35
No 47
Yes 20
No 21
p=0.521
History of Separation in
Childhood (n=72)
Yes 16
No 29
Yes 11
No 16
p=0.458
History of Sexual Abuse
Yes 5
No 77
Yes 2
No 39
p=0.783
Yes 6
No 76
Yes 8
No 33
p=0.045
Age (in 2005)
History of Physical Abuse
9
Months in placement
(until 2005)
LSP self care score
53.30 (56.73)
31.46 (40.31)
p=0.068
27.90 (6.17)
28.80 (6.70)
p=0.459
LSP social contact score 14.82 (3.80)
14.83 (4.35)
p=0.987
LSP Non-turbulance
score
40.74 (5.15)
40.80 (6.66)
p=0.501
LSP Responsibility Score 16.29 (3.08)
15.93 (2.82)
p=0.524
LSP Communication
Score
LSP Total score
18.73 (3.32)
20.37 (2.35)
p=0.006
118.49 (15.30)
120.73 (15.96)
p=0.451
Total number of met
needs
6.82 (3.51)
5.95 (3.67)
p=0.206
Total number of unmet
needs
1.43 (2.45)
2.05 (2.65)
p=0.296
Total number of needs
8.24 (3.46)
8.00 (3.96)
p=0.726
Cads alcohol score
1.40 (0.61)
1.59 (0.74)
p=0.182
Cads drug score
1.20 (0.62)
1.39 (0.89)
p=0.242
SPRS A score
0.35 (0.67)
0.32 (0.79)
p=0.341
SPRS B score
0.48 (1.19)
0.39 (0.95)
p=0.684
SPRS C score
0.34 (0.84)
0.66 (1.20)
p=0.047
10
SPRS D score
0.16 (0.53)
0.15 (0.57)
p=0.825
SPRS Total score
1.33 (2.44)
1.51 (1.99)
p=0.346
Yes 16
No 45
Yes 10
No 26
p=0.868
Yes 17
No 44
Yes 14
No 44
Yes
No
Yes
No
5
31
12
24
p=0.112
Being on Antidepressants Yes 23
(in 2005)
No 37
(n=95)
Being on Anticholinergics Yes 26
(in 2005)
No 33
(n=94)
Reports of non-adherence
(since 2005)
Yes 30
No 52
Yes 4
No 31
p=0.005
Yes 8
No 27
p=0.039
Being under Section
MHA (in 2005)
Yes 9
No 32
Being on Depot
Antipsychotics (in 2005)
(n=97)
Being on more than 1
Antipsychotics (in 2005)
(n=97)
Being on a Mood
Stabilizer (n=96)
Yes 6
No 76
p=0.487
p<0.001
Yes 38
No 3
p=0.019
11
Table 3. Characteristics of patients investigated for their association with outcome
Variable
Age in 2005 (per
year older)
OR
0.970
95% CI
0.922 to 1.021
p-value
0.248
Length of illness in
2005 (per year)
1.035
0.982 to 1.092
0.203
Any non-adherence
with medication
2005-2010
8.596
3.405 to 21.700
<0.001
SPRS C Score in
2005
1.174
0.416 to 3.313
0.669
LSP Communication
Score in 2005
0.908
0.584 to 1.413
0.179
Detained
involuntarily in 2005
0.336
0.074 to 1.532
0.159
History of physical
abuse in childhood
2.004
0.523 to 7.680
0.311
SPRS7 = Special Problems Rating Scale, a measure of challenging behaviours
LSP5 = Life Skills Profile, a measure of social functioning
12
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14